LEARNING OBJECTIVES PPMI IN ACTION: OPTIMIZING THE USE OF PHARMACY EXTENDERS Moderator: Dan Newberg MS, RPh, FMSHP, FASHP Director of Pharmacy Beverly Hospital 1. Describe the term pharmacist extender 2. Differentiate work that can or cannot be delegated to a pharmacy student 3. Relate how the use of technology can be used to expand the role of pharmacy technicians 4. Explain how pharmacy services were reengineered to support technicians as part of the patient care team Goal of the 2010 Pharmacy Practice Model Initiative Develop and disseminate a futuristic practice model that supports the effective use of pharmacists as direct patient care providers. Major PPMI Themes Goal 1 PPMI National Dashboard Goal 2 Goal 3 Goal 4 Goal 5 Move pharmacists closer to the patient Responsibility for safe use of medications and ensuring quality Well-developed technician workforce Pharmacist roles, practices, and activities will improve medication use and optimize medication related outcomes. Pharmacy technicians will prepare and distribute medications and perform other functions that do not require a pharmacist's professional judgment. Pharmacists and pharmacy technicians will have appropriate training and credentials for the activites performed within their scope of practice. Pharmacy departments utilize available automation and technology to improve patient safety and improve efficiency. Pharmacists will demonstrate leadership in exercising their responsibility for medication use systems and will be accountable for medicationrelated patient outcomes. Wide-spread use of technology 0 1
Objectives PPMI in Action Optimizing the use of Pharmacy Extenders: A Team-Based Technician (TBT) Program Melissa A. Ortega, Pharm.D., M.S. Pharmacy Manager, Acute Care Operations 1. Describe the term pharmacist extender 2. Differentiate work that can or cannot be delegated to a pharmacy students and/or pharmacy technicians 3. Explain how pharmacy students, pharmacy technicians, and the use of technology can extend the reach of pharmacy services 7 8 PPMI Vision and Goals Role of Pharmacy Extenders: Technicians Vision of PPMI To create passion, commitment, and action among hospital and health-system pharmacy practice leaders to advance the health and well being of patients by optimizing the role of pharmacists in providing direct patient care Goal of PPMI To implement the vision by support a futuristic practice model Describes how pharmacy resources are deployed to provide care. How pharmacists practice and provide care to patients How technicians are involved to support care Use of automation/technology in the medication use system. Advancing technicians role is the nation s lowest score 28% compliance with recommendations in Massachusetts Technicians utilized to their full potential complete the following: Tasks that do not typically require specialized clinical knowledge, judgment, and skill Management of pharmacy department information technology systems Detective work and documentation for med safety or quality assurance (QA) programs Initiation of medication reconciliation or medication history collection for pharmacist review 9 AJHP 2010;67:542 2013 PPMI Aggregate date for Massachusetts. Reported by American Society of Health-System Pharmacists (ASHP) and the ASHP Research and Education Foundation 10 Am J Health-Sy st Pharm Vol 68 Oct 1, 2011 Pilot Study: Pharmacist and Pharmacy Technician Managed Program Trending of Patient Satisfaction Scores Pilot Study Admission Medication Reconciliation for a Geriatric Service Line-Funded August 2012- July 2013 Created and validated procedures for admission med rec Defined the process, tools, and how to utilize resources effectively Collected baseline data to determine the impact of service Avoided adverse drug events associated with med rec Included 918 patients admitted to Gen Med or Geriatrics Found at least one discrepancy on 51% of patients Pharmacy Services Timeline of Events PGY-2 Transition Transition in Pharmacy Plans to PO funded study of pharmacist-and In Care Project Care becomes a council 25% of pharmacy technician managed 500 inpatients strategic initiative adult inpatients medication history reconciliation educated End Date July 2012 Resca K and Smith E. PO Grant: Pilot Study Admission Medication Reconciliation for a Geriatric Serv ice Line. MSHP 2014 Annual Poster Session Massaro F, Graham 11 J, Thompson R. Study Report Impact of a Pharmacy-based Team on Improving Patients Safe and Effective Use of Medications. Tufts Medical Center Physicians Organization Grants Committee. August 2013. 12 2
How Can We Continue Without More Staff Pharmacy Council Work 1 2 3. Goals with existing resources Prioritize and continue medication reconciliation on admission service Improve current processes and operations to become more efficient Utilize technicians as pharmacy extenders to provide additional pharmacy services and impact medication therapy outcomes Pharmacy Practice, Operations Improvement, and Technician Advancement Evaluated the activities/services currently performed by pharmacists and technicians Determined activities/services that could be reassigned or streamlined Identified distributive functions completed by the pharmacists Automated reports to drive operations and decisions Defined a new technician model 13 14 A Successful Equation Team-Based Technician Model Now at your service Monday Friday Use of automation and technology Efficient operations and processes Redesign and redeploy resources Technicians oriented into each pharmacy service team Critical care, Pediatrics/Perinatel, Cancer, Med/Surg, and Central Support Proactive in owning medication distribution versus reactive to service requests Finding and retrieving missing doses Facilitating the delivery of STAT medications Advising on regulatory standards on med handling and storage Evaluating infusion rates of IV drips Support pharmacists in conducting medication histories within the first 24 hours of admission 15 16 Reassigned and Reorganized the Work Implementation Team-Based Technician Program Pharmacist time devoted to clinical services Pharmacy core services provided to every patient, every day Targeted services for high risk or complex patients / therapies Pharmacy technicians as pharmacist extenders Assisting pharmacists in completing tasks (data collection, override reports, audits, etc.) Nursing staff to page technicians for drug distribution / service issues More interactive in patient care areas Ownership of drug distribution, storage, and security Internal recruitment Interviewed with pharmacists in each patient care team Established service-based criteria for new TBT role Daily activities and workflow Replicated procedures and tools for admission medication reconciliation from the pilot study Aligned with pharmacists daily activities and service team Training Rotations Quality Assurance (QA) program Systematic process of checking to see whether service being developed is meeting expectations Audits and metrics 17 18 3
Team-Based Technician Curriculum and Training Team-Based Technician Quality Assurance Program Rotation 1- Medication distribution oversight Interpreting and running ADC reports Override and drip round procedures Medication storage and use policy Unit inspection forms and temperature procedures Rotation 2- Medication history collection Admission medication reconciliation process and shadow Medication Reconciliation and interview guideline Pharmacotherapy Review Rotation 3- Professionalism and customer service Hospital Professionalism and etiquette Guideline ICare The Patient Experience Infection Control Shadow nursing staff 19 Medication distribution Optimizing inventory and maintenance of ADCs Medication unit inspections Medication history collection Prioritizing patients and accurately collecting a patient s medication history using various sources Clear communication with the pharmacist about discrepancies While Interviewing stating it s important to ALWAYS know about your medications Professionalism and customer service Following proper infection control techniques Showing exceptional bedside manner Clearly communicating with the patient and respecting the patients feelings 20 Impact of Team-Based Technician Program Anticipated Outcomes When We Succeed What Will We Have? Reorientation of technician responsibilities has enabled increased involvement in collecting medication histories 500 80 450 70 For our Technicians Empowerment to provide drug distribution services More engaged and productive pharmacy technician workforce Greater accountability for customer service to team-based units 400 350 300 250 200 60 50 40 30 Adult Admission Med Rec Completed, n HCHAPS- Communication about Medications, Score (target > 68%) Adult Admission Med Rec Completed per Hospital Admission, % For the Department of Pharmacy More engaged and productive pharmacist workforce Working at the Top of Your License! Increased patient interaction / education Improved consistency, safety, reliability of medication use system 150 100 50 0 August September October November December January 21 20 10 0 For our Patients Improved patient satisfaction (HCAHPS) and medication outcomes Decreased readmissions and adverse drug events 22 CONFLICT OF INTEREST / DISCLOSURE PPMI IN ACTION OPTIMIZING THE USE OF PHARMACY EXTENDERS Shawn Roggie, PharmD, MBA, BCPS Baystate Medical Center No conflicts to disclose 4
LEARNING OBJECTIVES 1. Describe the term pharmacist extender 2. Differentiate work that can or cannot be delegated to a pharmacy student 3. Relate how the use of technology can be used to expand the role of pharmacy technicians 4. Explain how pharmacy services were reengineered to support technicians as part of the patient care team PHARMACIST EXTENDER Described sporadically in the pharmacy literature Traditionally considered as a pharmacy technician or aid More recently in ASHP s PPMI initiative includes residents and students Working definition an individual whose work is delegated and overseen by a pharmacist and allows the pharmacist to accomplish work that otherwise would not be possible IMPETUS TO CHANGE ACPE Increased Technology Increased Student Integration Budgetary Labor Constraints Student Needs and Expectations ACPE DRAFT STANDARDS 1 Released in February for review Key elements include: Patient Care emphasis Diverse patient populations Interprofessional experiences Timing Duration Required vs. elective experiences Geography Design of rotations requires careful thought and balance OTHER DRIVERS Hospital pharmacy budget Increased technology Student expectations Competitive labor market demands the demonstration of skills Residency Others Hospital, nursing units demand value OUR JOURNEY Traditional student (APPE) rotations PGY-1 residency added Hospital administration challenge to do more Colleges challenge to do more PPMI ups our game Self-assessment challenge to provide more oversight of drug therapy 2 More credentialed staff 5
OUR CHALLENGE What responsibilities can we delegate to our residents and students? Residents are licensed (eventually) but cyclical Students (interns) are permitted but VERY cyclical Development of ideal tasks that can be delegated ISSUES FOR CONSIDERATION WITH STUDENT RESPONSIBILITIES Students are not employees Variability in skill sets (and interest level) Not available 7 days per week Balance needs of institution with needs of the student (ACPE) Pharmacist oversight availability TASK DELEGATION TO STUDENTS Ideal Task Characteristics Provides value to the patient Pharmacist oversight available Is ok to be interrupted Or Can be picked up when student not available Non-Ideal Task Characterists Busy-work or difficult to measure value Novel programs that institution is not experienced in Must-have programs WHAT PROGRAMS CAN YOU THINK OF THAT COULD BE DELEGATED AT YOUR INSTITUTION TO A STUDENT (APPE OR IPPE) - TAKE THREE MINUTES EXAMPLES OF SUCCESS Literature abounds EXAMPLES OF SUCCESS AT BAYSTATE Vancomycin monitoring Heart Failure and ACS discharge counseling Prescription capture at discharge Medication Reconciliation pilots Research associates *All have been initiated and led by longitudinal students 6
REFERENCES 1. Accreditation Council for Pharmacy Education. Accreditation standards and key elements for the professional program in pharmacy leading to the doctor of pharmacy degree. Draft standards 2016. Chicago, IL. 2014. PDF File. 2. American Society of Health-System Pharmacists. PPMI hospital self-assessment. Bethesda, MD. 2014. PDF File. Use Of Certified Pharmacy Technicians in the Sterile Products Room to Manage Final Check Before Dispensing Deanna J Choquette, CPhT April 1, 2014 Objective Beverly Hospital, A Member Of Lahey Health Evaluate how the use of technology in the sterile products room and the expansion of the technician as pharmacy extenders allows pharmacists to focus on improving patient outcomes. 39 Important Numbers Beverly Hospital pharmacy services 341 acute care beds, as well as provides extensive outpatient services. Approximately 2.2 million doses are dispensed per year; 48,000 of those doses are compounded IV doses made on-site at Beverly Hospital pharmacy. In October 2012 we implemented an automated IV workflow management system to help manage some of these doses. What is an IV Workflow Manager? Any of the IV Workflow managers include the following components: A queue populated by order entry prioritizing doses by due time. Bar-code verification software. Step-by-step instructional screen possibly requiring photographs at important steps. A remote verification system to allow log-ins and checks by pharmacists 41 42 7
Why Automate Sterile Products Compounding? Automation exists in many aspects of dispensing. Helps reduce/catch errors & track waste. Technicians using technology to pre-verify refocuses pharmacists from dispensing to clinical duties. Good judgment is required by technicians to look for and resolve inconsistencies. Medication Error The use of an automated IV workflow manager with barcode verification helps by reducing the risk of certain compounding errors before they occur. When an incorrect med is scanned, preparation is not allowed to continue until the correct med is scanned. 1. Saves time spent preparing incorrect meds. 2. Reduces waste from preparing incorrect meds. 3. Saves pharmacist time spent checking incorrect doses. 43 44 Benefits of image-capture on safe workflow However. Provides audit trail. More accurate than syringepullback method. Does not tie pharmacist to the cleanroom (reducing personnel in the cleanroom, and saving gowning time for pharmacists). Many pharmacists are initially uncomfortable relinquishing control of the final check to technicians. No longer holding the final product makes them concerned about: 1. Checking for particulates 2. Checking for color changes 3. Checking for leaks 4. Checking for proper labeling, including auxiliary labels. Ensures only one dose/batch is prepared at a time. 45 46 Safety Controls Overcoming Resistance to Change The expanded role of technicians in dose preparation means verifying that the final product is free of particulate matter. Use of a white and black light box and a magnifier can help technicians ensure safety of the final product. It will take time and practice with the system to reach a comfort level as both competency with the system & understanding it s benefits increase. 47 48 8
PPMI Applications & Conclusion Enhances the role of technicians through technology as recommended in the 2014-2018 ASHP Pharmacy Forecast and is a step toward advanced roles for technicians An expanded technician role will lead to more standardizedtraining. Empowering technicians takes pharmacists from being active in dispensing to be more active in patient care. Remote verification of CSP s allows for a more focused workflow for pharmacists with less interruption to enter the cleanroom. Works Cited Cobaugh, Daniel J., and David Chen. "Pharmacy Practice Model: Likelihood of Achieving Key Milestones." (n.d.): n. pag. Rpt. in Pharmacy Forecast 2014-2018: Strategic Planning Advice For Pharmacy Departments in Hospitals and Health Systems. December 2013 ed. Bethesda: American Society of Health-System Pharmacists Research and Education Foundation, 2013. 21-24. Print. Cooley, Tom, Silvia Maranian, Michael McGregory, Allen Seiger, Kim Sherman, and David Tjhio. "ASHP Section Of Pharmacy Informatics And Technology." Proc. of Current State of IV Workflow Systems and IV Robotics. ASHP n.d.: 1-8. ASHP. Web. <http://http://www.ashp.org/doclibrary/membercenter/sopit/current- State-of-IV-Workflow-Systems-and-IV-Robotics.pdf>. "Executive Summary." American Journal of Health-System Pharmacy 68.12 (2011): 1079-085. Print. Hillman, Jennifer. "Employ Automation to Increase IV Preparation Safety." Pharmacy Purchasing & Products 10.11 (2013): 18-21. Pharmacy Purchasing & Products Magazine. Web. 8 Feb. 2014. Myers, C. E. "Opportunities and Challenges Related to Pharmacy Technicians in Supporting Optimal Pharmacy Practice Models in Health Systems." American Journal of Health-System Pharmacy 68.12 (2011): 1128-136. Print. "Post-Production IV Admixture Checks Less Than Ideal." ISMP Medication Safety Alert! Acute Care 15.13 (2010): 3. Institute for Safe Medication Practices. Web. 8 Feb. 2014. Proc. of ISMP Sterile Preparation Compounding Safety Summit: Guidelines for SAFE Preparation of Sterile Compounds, North Convention Center, Room South Pacific J, Las Vegas, NV. N.p., n.d. Web. 8 Feb. 2014. Siska, M. H., and D. A. Tribble. "Opportunities and Challenges Related to Technology in Supporting Optimal Pharmacy Practice Models in Hospitals and Health Systems." American Journal of Health-System Pharmacy 68.12 (2011): 1116-126. Print. Speth, Stephen. "Automating IV Dose Management." Pharmacy Purchasing & Products 8.11 (2011): 50-52. Pharmacy Purchasing & Products Magazine. Web. 8 Feb. 2014. 49 50 9